Appropriate documentation- why it matters

1 Appropriate documentation - why it matters Eric Cornatzer MD Baptist Princeton Hospital Disclosures Nothing to disclose Purpose Why clinical documentation is important To provide general overview of clinical documentation Improvement (CDI) Case Mix index Risk of Mortality Severity of Illness A general overview of Medicare payment structure with hospitals Discussion of general trends in CDI and ICD 10 implementation Physician Engagement Strategies Some Quotes to start the discussion And then the documentation is gone, and all that s left is a set of numbers. Pamela P. Bensen MD, Physician documentation Educator Physicians should maintain accurate and complete medical records and documentation of the services they provide . Physicians also should ensure that the claims they submit for payment are supported by the documentation . Good documentation practice helps ensure that your patients receive Appropriate care from you and other providers who may rely on your records for patients past medical histories.

2 CMS A case example 68 YO WM past medical hx HTN presents to ED with 3 day history nausea, vomiting and poor po intake with new onset melena. States has been taking 6-8 ibuprofen daily for a year for chronic lower back pain. Presentation Vitals Temp HR 110, RR 24 BP 180/120 Gen: Laying in bed covered in blood, in obvious distress HEENT: Conjunctival pallor Lungs: tachypnea, no accessory muscle usage CV: Tachycardia no rubs murmurs or gallops Case continued Labs: Hematocrit 21 WBC Creatinine , baseline Bicarbonate 18 Patient is started on IVF, Protonix gtt, admitted to ICU and gastroenterology is consulted, type and crossed 2 units, and transfusion started. Patient received IV hydralazine, and ace inhibitor held. Physician #1 admits patient with Principle problem of UGIB with secondary problems of ARF, anemia and dehydration. Physician #2 admits patient with principle problem Acute kidney injury secondary to probable acute tubular necrosis, secondary diagnosis of SIRS of non infectious origin with acute organ dysfunction How Medicare views our patient Physician 1: MS DRG 379 hemorrhage without cc/mcc Relative Weight/Case mix index Physician 2: MS DRG 682 Renal failure with mcc Relative weight/Case Mix index Same patient viewed differently by two different providers.

3 What is the cost to treat the patient? Which patient to you would require utilization of more resources during their stay? Which patient would require a longer length of stay? What is the phenomenon of physicians seeing same patient but labeling different diagnosis called? What is clinical documentation Improvement? clinical documentation improvement is not up-coding clinical documentation improvement is not about making more paperwork for physicians clinical documentation improvement is an accurate reflection of a patients Severity of Illness, and Risk of Mortality at the time a physician evaluates the patient. It is a reflection of the diligent care that you the practitioner is giving to your patient during their hospitalization. Why is it important 87% of patient would choose a different hospital based upon information on quality 82% of patients would choose a different provider based on quality information 69% of patients want hospitals to publicize outcomes 71% of patients would be influences if a hospital refused to submit data on clinical performance general tenets of CDI Be clear why your patient came in If a diagnosis is underlying cause why the patient is in hospital.

4 Explain why. Be specific with your diagnosis Label whether present on admission Label whether something is expected post operatively or a subsequent complication Physical exam should reflect the patients actual status Primary Diagnosis or DRG Secondary Diagnosis MCC/CC/or no CC POA SOI ROM Post operative complications Hospital Stay MS DRG Secondary Diagnosis Relative weight Case Mix Index Reimbursement Diagnosis related Groups-Principle Diagnosis Medicare Severity DRGs (MS-DRGS)-used by Medicare All Patient Refined DRGS (APR-DRGS)- used by many Medicaid programs, quality metrics All Patient DRGS- Used by some payers Relative Weight- conversion of diagnosis to numeric form to reflect length of stay, severity of illness, and resource utilization Hospital Blended Rate- total dollar amount assigned to a hospital to calculate MS DRG reimbursements (Base rate x Local income variations x Residents/beds x Disproportionate share) Geometric Length of Stay- national mean length of stay for MS DRG Case Mix index (Total Relative Weight/#Discharges) MS DRGS Medicare uses a simple algorithm Main Principle Diagnosis/Surgical Procedure Secondary Diagosis MCC CC Non-CC MS DRG Primary Diagnosis MCC CC No CC Secondary Diagnosis Relative Weight Case Mix index.

5 A comparison between hospitalists Hospitalist #1 CMI LOS days Bounceback rate 3% CHF admissions Hospitalist #2 CMI LOS days Bounceback rate 5% CHF admissions APR-DRGS Proprietary, severity adjusted system used by quality assessment programs suchs as AHRQ, and database preforming reporting systems Follows Main Driver: Principle diagnosis Difference is secondary diagnosis has 4 tier structure SOI 1- Minor SOI 2- Moderate SOI 3- Major SOI 4 Extreme APR DRG Primary Diagnosis SOI 1 SOI 2 SOI 3 SOI 4 Secondary Diagnosis Relative Weight Severity of illness Levels APR-DRG MS DRG AHRQ Quality indicators PSI- Patient Safety Indicators PQI- Patient Quality Indicators IQI- Inpatient Quality Indicators PDI- Pediatric Quality Indicators AHRQ Quality Indicators Based on UCSF protocol Mortality rates for conditions Acute myocardial infarction (AMI) ] ,AMI without transfer ,Congestive heart failure , Gastrointestinal hemorrhage ,Hip fracture , Pneumonia ,Acute stroke Mortality rates for procedures Abdominal aortic aneurysm repair, Coronary artery bypass graft, Craniotomy , Esophageal resection, Hip replacement, Pancreatic resection , Percutaneous transluminal coronary angioplasty, Carotid endarterectomy Hospital-level procedure utilization rates Hospital Acquired condition PSI #90 Pressure Ulcer Stage III/IV Iatrogenic Pneumothorax Post operative sepsis, wound dehiscence, hip fracture, PTE/DVT CVC blood stream infection Accidental puncture or laceration CDC Abstraction CLABSI CAUTI Present on Admission accuracy Present on admission Work Setting Testing in timely fashion Physician awareness Present on Admission continued POA is defined as being present at the time the order for inpatient admission occurs.

6 Conditions that develop during an outpatient encounter (including emergency department, observation, or outpatient surgery) are considered POA; Inter-observer variability showed agreement on POA reporting in percent of records, with percent over-reporting and percent under-reporting. For-profit hospitals tended to overcode secondary diagnoses as present on admission (odds ratios [OR] ; 95 percent confidence interval [CI] , ), whereas teaching hospitals tended to undercode secondary diagnoses as present on admission (OR ; 95 percent CI , ). [3] Present on Admission A well-known dilemma is called inter-observer variability and constitutes a serious impediment in medical imaging. It has been known since the 1950s. The so-called inter-observer variability is sometimes so drastic that observers agree on only 50% of the total delineated volume and in other cases the agreement can even drop to 40% [4].

7 The same problem also applies to individual experts, who can mark the same image differently when they observe it for a second time. This is called "intra-observer variability" ICD 10 Coding 68,000 diagnosis codes 87,000 procedure codes ICD 10 will demand specificity from practitioners Practitioners can expect to see more coding queries Lucky some of the problem diagnosis from ICD9 carry over from ICD 10 ICD 10 Acute Myocardial Infarction Focus clinical documentation on identifying the date of onset of the MI and duration from onset of MI along with the type, anatomic location, and consequences of the MI. Asthma Discuss Severity, timing, and relationship with COPD, Bronchitis. Look fo acute respiratory failure Cerebrovascular Disease Focus documentation on specific type of hemorrhage or infarction, artery affected, and laterality. Providers can also specify occlusions or stenosis to an artery and laterality.

8 Coma Diabetes Focus documentation on specific type and subsequent complications ICD 10 Continued Fracture Focus documentation efforts on fracture type, laterality, and type of encounter Pregnancy Focus documentation on trimester in number of weeks, counted from the first day of the last menstrual period. Pressure Ulcer Focus documentation on specific ulcer documentation such as site, laterality, and stage Respiratory Failure Focus documentation on acute, chronic or acute-on-chronic respiratory failure along with hypoxemia or hypercapnia. Atrial Fibrillation Atrial Flutter Paroxysmal atrial fibrillation Persistent atrial fibrillation Chronic atrial fibrillation Unspecified atrial fibrillation Typical atrial flutter Atypical atrial flutter Unspecified atrial flutter Acute Kidney Injury ARF is not a diagnosis. Acute Renal Failure is one. Prognosis for patients with acute tubular necrosis is worse than compared to pre renal patients Dialysis is not required for a diagnosis of acute renal failure and does not impact MS-DRG assignment It is important to label causality ( AIN, ATN, GN) clinical documentation Codes SOI/ROM acute renal insufficiency Disorder of kidney and ureter 1/1 acute renal failure Acute kidney failure, unspecified 3/3 acute kidney injury secondary to acute tubular necrosis Acute kidney failure with lesion of acute tubular necrosis 4/4 chronic renal insufficiency Chronic kidney disease, unspecified 1/1 CKD, Stage III Chronic kidney disease, stage III 2/2 End stage renal disease End stage renal disease 3/3 CDI 2015 goals 1.

9 Focus on quality- not reimbursement. 2. Expand CDI efforts beyond Medicare. 3. Pair CDI specialists with coders. 4. Ease transition pains of ICD Physician engagement strategies Discover a common purpose. Adopt an engaging style and talk about rewards. Reframe values and beliefs to turn physicians into partners, not customers. Use engaging improvement methods by using data. Segment the engagement plan and provide education. Go ahead and identify champions for the quality improvement initiative. References Accuracy of Present-on-Admission Reporting in Administrative Data L Elizabeth Goldman, , , et al comparison of target delineation for MRI-assisted cervica cancer brachytherapy: Application of the GYN GEC-ESTRO recommendations, Johannes Dimopoulos, Veronique De Vos, Daniel Berger, Primoz Petric, Isabelle Dumas, Christian Kirisits, Carey B. Shenfield, Christine Haie-Meder, Richard P tter, Radiotherapy and Oncology 91 (2009) 166 172.

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